- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,497.00 / $5,497.00 / $5,497.00
| Facility | | $5,497.00 | $5,497.00 | $5,497.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,202.60 / $3,967.40 / $3,967.40
| Professional | | $3,202.60 | $3,967.40 | $3,967.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,107.00 / $3,107.00 / $3,107.00
| Facility | | $3,107.00 | $3,107.00 | $3,107.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,492.49 / $5,492.49 / $6,865.61
| Professional | | $5,492.49 | $5,492.49 | $6,865.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,245.15 / $2,245.15 / $2,245.15
| Facility | | $2,245.15 | $2,245.15 | $2,245.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,007.60 / $2,868.00 / $10,516.00
| Professional | | $2,007.60 | $2,868.00 | $10,516.00 |